1. (a) Each health benefit plan delivered or issued for delivery by an HMO must include an HMO delivery network which is adequate and complies with Insurance Code §843.082.
2. (b) There shall be a sufficient number of primary care physicians and specialists with hospital admitting privileges to participating facilities who are available and accessible 24 hours per day, seven days per week, within the HMO's service area to meet the health care needs of the HMO's enrollees.
3. (c) An HMO shall make general, special, and psychiatric hospital care available and accessible 24 hours per day, seven days per week, within the HMO's service area.
4. (d) If an HMO limits enrollees' access to a limited provider network, it must ensure that such limited provider network complies with the provisions of this section.
5. (e) An HMO shall make emergency care available and accessible 24 hours per day, seven days per week, without restrictions as to where the services are rendered.
6. (f) All covered services that are offered by the HMO shall be sufficient in number and location to be readily available and accessible within the service area to all enrollees.

7. (g) HMOs must arrange for covered health care services, including referrals to specialists, to be accessible to enrollees on a timely basis upon request and consistent with guidelines set out in paragraphs (1) - (3) of this subsection:

   1. (1) Urgent care shall be available:

      1. (A) within 24 hours for medical and dental conditions; and
      2. (B) within 24 hours for behavioral health conditions.

   2. (2) Routine care shall be available:

      1. (A) within three weeks for medical conditions;
      2. (B) within eight weeks for dental conditions; and
      3. (C) within two weeks for behavioral health conditions.

   3. (3) Preventive health services shall be available:

      1. (A) within two months for a child;
      2. (B) within three months for an adult; and
      3. (C) within four months for dental services.

8. (h) An HMO is required to provide an adequate network for its entire service area. All covered services must be accessible and available so that travel distances from any point in its service area to a point of service are no greater than:

   1. (1) 30 miles for primary care and general hospital care; and
   2. (2) 75 miles for specialty care.

9. (i) If any covered health care service or a participating physician and provider is not available to an enrollee within the mileage radii specified in subsection (h)(1) and (2) of this section because physicians and providers are not located within such mileage radii, or if the HMO is unable to obtain contracts after good faith attempts, or physicians and providers meeting the minimum quality of care and credentialing requirements of the HMO are not located within the mileage radii, the HMO shall submit an access plan to the department for approval, at least 30 days before implementation in accordance with the filing requirements in §11.301 of this title (relating to Filing Requirements). The access plan shall include the following:

   1. (1) the geographic area identified by county, city, ZIP code, mileage, or other identifying data in which services and/or physicians and providers are not available;
   2. (2) for each geographic area identified as not having covered health care services and/or physicians or providers available, the reason or reasons that covered health care services and/or physicians and providers cannot be made available;
   3. (3) a map, with key and scale, which identifies the areas in which such covered health care services and/or physicians and providers are not available;
   4. (4) the HMO's plan for making covered health care services and/or physicians and providers available to enrollees in each geographic area identified;
   5. (5) the names and addresses of the participating physicians and providers and a listing of the covered health care services to be provided through the HMO delivery network to meet the medical needs of the enrollees covered under the HMO's plan required under paragraph (4) of this subsection;
   6. (6) the names and address of other physicians and providers and a listing of the specialties for any other health care services or physicians and providers to be made available in the geographic area in addition to those physicians and providers participating in the HMO delivery network listed under paragraph (5) of this subsection;
   7. (7) the procedures to be followed by the HMO to assure that primary care physicians, general hospitals, specialists, special hospitals, psychiatric hospitals, diagnostic and therapeutic services, or single or limited health care service providers and all other mandated health care services are made available and accessible to enrollees in the geographic areas identified as being areas in which such covered health care services and/or physicians and providers are not available and accessible, and any plans of the HMO for attempting to develop an HMO delivery network through which covered health care services are available and accessible to enrollees in these geographic areas in the future; and
   8. (8) any other information which is necessary to assess the HMO's plan.
10. (j) The HMO may make arrangements with physicians or providers outside the service area for enrollees to receive a higher level of skill or specialty than the level which is available within the HMO service area such as, but not limited to, transplants, treatment of cancer, burns, and cardiac diseases. An HMO may not require an enrollee to travel out of the service area to receive such services, unless the HMO provides the enrollee with a written explanation of the benefits and detriments of in-area and out-of-area options.
11. (k) The HMO shall not be required to expand services outside its service area to accommodate enrollees who live outside the service area, but work within the service area.
12. (l) In accordance with Insurance Code Article 21.53F (Telemedicine), each evidence of coverage or certificate delivered or issued for delivery by an HMO may provide enrollees the option to access covered health care services through a telehealth service or a telemedicine medical service.

Source Note:The provisions of this §11.1607 adopted to be effective November 2, 1998, 23 TexReg 11347; amended to be effective July 31, 2002, 27 TexReg 6701; amended to be effective February 24, 2005, 30 TexReg 854.